Covid-19 for the general medicine doctor

Introduction

Right people. We’re in a lockdown. I’m not a covid-19 expert. Of course, no-one is, but lots of others have better claims to being one than me. I like looking after older people. But I was meant to go to Morocco for a week, and I’ve stayed on leave. I don’t really enjoy social isolation. And I like reading. I’ll try to keep this up to date. But no promises. There are loads of links to resources here so read them yourself and draw your own conclusions please. In fact don’t use this page for anything else than your own enjoyment. This isn’t a set of recommendations and things will change rapidly, I’m sure

Sean, update 7th April 2020

Guidelines

I’ve read some of you are learning about ventilator settings but I’m going to leave that for now. A decent starting point for hospital clinicians would be guidance on deciding who to admit, the NHS England guidance on assessment and management and the WHO guidelines on managing severe acute respiratory infection when novel coronavirus suspected.

The surviving sepsis team have also produced guidance specifically for novel coronavirus – a useful summary for managing critically unwell patients

Here are some links to specialty specific guidelines for COVID-19. I looked at the respiratory ones.

Review articles

What can we learn from the outbreak in China? Here is a summary of the epidemiological characteristics and lessons from 72,314 cases.

That poor guy that stands behind Trump wrote this. Coronaviruses – more than just the common cold.

Clinical features

There are lots of studies reporting case series from China. Here are a few describing the features of the disease.

Characteristics of coronavirus patients Jan 1- Jan 20 in Wuhan – Chen et al.

The most common features were fever (83%), cough (82%) and shortness of breath (31%) 75% had bilateral pneumonia

Clinical characteristics in Wuhan between December and January of 1099 patients. (Guan W-J et al.)

There was fever at presentation in 44% of patients and developing during admission in 89%. Other common symptoms were cough (68%), fatigue (38%) and sputum production (34%)

Wang et al. report common symptoms as fever (98.6%), fatigue (69.6%), dry cough (59.4%) and myalgia (34.8%). 10% presented with diarrhoea and nausea 1-2 days prior to fever and dyspnoea.

In Zhejiang province (Xu X-W et al.), milder disease was present. The most common symptoms were fever, cough, expectoration, headache, myalgia or fatigue, diarrhoea, and haemoptysis.

Old age, high SOFA score, neutrophilia, organ dysfunction and high d-dimer were associated with poor outcomes see e.g. Wu et al. and Zhou et al. and Zhu et al.

Most of our studies are from hospitalised patients, at one end of the clinical spectrum. On a quarantined cruise ship, 51% of confirmed cases were asymptomatic at time of testing.

The ENT crew want to tell you about anosmia as a symptom of covid-19. The gastroenterologists want to tell you about GI symptoms and us geriatricians want to warn you about delirium, falls and immobility. I’m sure other societies have already followed suit with statements.

Non peer-reviewed data provides an idea of the range of symptoms.

What does all this mean? Like most diseases, there is a well recognised set of clinical and pathological characteristics, but there is also variation and it can present atypically.

Tests





There has been a lot of chatter about laboratory abnormalities including raised ferritin, raised d-dimer, raised CRP, elevated LDH, leucocytosis and leucopenia, all noted in the studies above but a lot of patients had pretty normal looking blood tests also. The most common relevant findings seemed to be lymphopenia (which I suddenly started seeing in my older inpatients in the last few weeks because I’ve started looking for it) but we’re being asked to do routine troponins, and then …., presumably because cardiologists really like being called about raised values in critically ill patients. Until someone publishes some likelihood ratios for these tests, I’m not going to be using d-dimers to diagnose Covid-19. If you want to read about coagulopathy in covid-19 (as much as we know for know), try this. It’s not clear (yet) there is more thromboembolism in Covid-19 than there is in other critically ill patients.

The British Thoracic Imaging Society has summarised the radiological features of the disease, which you’ve probably read about elsewhere (bilateral ground glass opacities with a peripheral and lower lobe predilection) and can see more examples of here. Of course these features can overlap with other diseases, including other viral pneumonias, so “clinical correlation is advised.”

How sensitive are swabs at picking up the disease? Probably around 70% but it depends on quality and type of sample…

The CEBM compares evidence for oropharyngeal vs nasopharyngeal swabs. The evidence isn’t of great quality.

Here’s a study looking at the Detection of SARS-CoV-2 in different types of clinical specimens. The most positive results were in BAL, followed by sputum. This study suggests you cannot rely on nasal and pharyngeal swabs to rule out the disease.

But you’re the type of doctor that knew that you can have a disease with a negative test already, aren’t you? Interestingly the virus was also detected in stool suggesting potential non-respiratory route of transmission although as far as I know no-one has confirmed non-respiratory spread yet (26/3/20).

Here is the WHO guidance for testing as of 19th March

“If a negative result is obtained from a patient with a high
index of suspicion for COVID-19 virus infection, particularly
when only upper respiratory tract specimens were collected,
additional specimens, including from the lower respiratory
tract if possible, should be collected and tested”

A head scratcher of a Study in JAMA of just 4 patients who had recovered from coronavirus. Recovery was clinical, radiological, and based on 2 negative throat swabs. However, repeat swabs during follow up were all positive whilst asymptomatic. No family members infected. This raises more questions about the performance of the test and how that translates to transmission.

The summary of all this, is if it’s negative and you have a clinico-radiological syndrome consistent with COVID-19, you probably need to keep them isolated and test again. And we’re still learning about the virus. Also a reminder that you can’t rely too much on tests in medicine. These sort of issues exist in many other areas of medicine, too.

Management of critically ill patients

Here is a short summary article about managing critically ill patients in JAMA, march 2020 whilst NHS England guidance is here.

The Resuscitation Council have updated their guidelines for providing CPR in confirmed or suspected COVID-`19, but please familiarise yourself with your hospital protocol. The role of CPR is pretty controversial.

NICE has released specific guidance on assessment of patients who might need critical care. They suggest, considered use of the clinical frailty scale. Crucially this means finding out what a patient was like before they became acutely unwell, usually two weeks ago and asking questions around exercise tolerance and functional ability like cooking, cleaning, shopping, finances, and leaving the house. If this isn’t standard practice in your organisation it’s going to become it so try this e-learning. If you’re going to be looking after frail older people, and aren’t use to this try these resources.

I already mentioned WHO guidance the Surviving sepsis guidance – they both have useful summaries of managing critically unwell patients, much based upon research from other diseases. A few things have changed in the last few years. How about not using too much oxygen (after initial resuscitation), and aiming for oxygen saturations between 92-96% once the patient is stabilised).

For fluid therapy, use dynamic clinical parameters such as capillary refill time and lactate to assess fluid responsiveness. Have you ever done a passive leg raise? Maybe we should use buffered solutions rather than saline for critically ill patients too, and be careful about using too much fluid after an initial trial for fluid responsiveness, particularly in patients with ARDS.

Here is the BTS guidance on non-invasive ventilation. I can’t really find good data on management of hypoxaemic respiratory failure in COVID-19 patients. We got excited about CPAP based upon hearsay suggesting there was a greater role for CPAP then we are used to for pneumonia. If you want to listen to some experts from England, USA, Italy and Spain debate the role of NIV try this. CPAP does seem to have the advantage of using up less oxygen. There is a nice narrative review on the subject within a usefully titled article called “Respiratory advice for the non-respiratory physician.” I will explain to my patients suitable for escalation that it is available, but we don’t know how good a treatment it is, for those where this is the ceiling of care. For fitter patients suitable for full escalation, I shall leave the matter for my clever ICU colleagues.

PPE

I’ve given up on debating this, or trying to keep on top. I’ll do what my stressed out colleagues do. Positions have flip flopped whilst wordwide there are concerns re: shortages. Everyone is anxious so if we can, let’s get the equipment to staff so they can feel safe enough to do their jobs. If you want to understand the recommendations, try this. If you want to chew over some evidence try the CEBM review of standard facemasks versus N95 respirators. The evidence isn’t great but face masks are probably just as good and issues about supply extend internationally, in better resourced healthcare systems. Masks are only one part of a complex intervention so read the review. A recent meta-analysis comparing their efficacy is here. If you want to consider what to do if all the N95 respirators and facemasks run out, try this, or (less seriously!) this…

On a different note, you may be concerned about the reports of healthcare workers affected with the disease. The Oxford CEBM team have looked at the effect of viral load and severity of disease. Stay safe.

Palliative care

Good palliative care is a key part of geriatric medicine. I routinely ask my inpatients about resuscitation, whether they seem imminently at risk of dying or not (if they want to, I don’t force it on them but it’s started a conversation that might be easier the next time). It’s not hard, and very rarely causes upset, when done sensitively. Whether or not they are at risk of dying, then it is worth knowing how they want to be treated, where they want to be treated, and indeed whether they want curative treatment. It’s the easiest thing in the world to admit for “24 hours” (that can turn into a lengthy admission), agree a “DNAR,” when a slightly better conversation may have yielded information like “they would never have wanted this.”

This is very different from writing off frail older people, many of whom have had rich lives, and may have different values to us – and not everyone fears old age and disability like some doctors seem to do. Even in this pandemic, I would urge that we are curious about our patients. Who are they? What did they do? (try just asking about occupation and hobbies as a starter) What are they proud of? What matters to them? From the retired headmaster who doesn’t want to be bossed around by young people to the nonagenarian arsenal fan who wants the season to start again, anecdotes and personal trivia will colour in your day and make it easier to have more meaningful conversations when it matters. Ask the team to gather this kind of info whilst delivering care.

Thanks to Dr Lara Mitchell for this nice infographic about difficult conversations, and as we face the reality that loved ones might not be at the bedside a guide to compassionate conversations by telephone from Dr Antonia Field-Smith.

Some other good resources to look at for tips on starting conversations from Dying Matters and the US Serious Illness Conversation Guide.

Delivering palliative care to patients with Covid-19 has its own specific challenges. Lucky then that our palliative care colleagues in Leeds have made this freely available.

Transmission

The median incubation period is estimated at 5 days. 97.5% of patients symptomatic by 11.5 days. 1 in 10,000 don’t develop symptoms within 14 days. Study in Annals of Internal medicine. This is based on hospitalised patients though. This non peer-reviewed article, featured on Richard Lehman’s excellent blog, here for a comeback tour, suggests a longer incubation period, with knock on effects for quarantine. It’s all very complicated. The virus can be detectable for some time, in stool for longer than sputum and saliva with longer duration, later peak  and higher load in patients with severe disease but virus shedding doesn’t always mean live virus that is transmissible.

Early transmission dynamics of novel coronavirus in Wuhan – NEJM Description of the initial spread in Wuhan

How long does the SARS-CoV-2 stay on surfaces for? The virus was detectable 72 hours after application to plastic, after 48 hours on stainless steel, less than 24 hours on cardboard. Titres drop over that period.

When can you end patients home or move them out of isolation? CDC guidance is here. But we are still learning….(see above!)

Pandemic management

Why were things so bad in Italy? Some insights here.

Does social distancing work? I hope so. Should Liverpool be allowed to get on and win the Premier league?

Here is the Imperial study that the government used to model various effects of interventions. It’s worth noting that in all the models, interventions last for months and the disease comes back (until there’s a cure, or an effective vaccine, for a virus that doesn’t mutate too much), although hopefully we can reduce deaths significantly…

There’s an Oxford study that suggests there may have already been a lot of transmission of novel coronavirus in the UK. Read an expert critique in the thread below.

This is the Government assessment of coronavirus impact without intervention. Very worrying predictions of up to 80% of population infected, 44% of over 80s hospitalised, 20% of over 80s who are hospitalised dying, 50% of those ventilated dying. Let’s hope social distancing works.

Here is the Government report on potential impact of behavioural and social interventions on an epidemic of Covid-19 in the UK

This is the government’s view on public gatherings. Expert opinion on impact of combined behavioural and social interventions suggests multiple interventions required.

Just so you know, despite news reports saying he think everything is hunky dory, Neil Ferguson (Imperial author) still believes that the intensive social distancing, and other interventions currently in place (26/03/20) are required to keep deaths down.

Should we have gone harder on international travel, earlier? You can delay the start of a local epidemic if you implement it at the early phase but there is a limited evidence base, that suggests limited effectiveness in controlling pandemic influenza.

Controversies

The ACE 2 enzyme converts angiotensin II to angiotensin I and is a co-receptor for viral entry for SARS-CoV-2. There is a concern that ACE inhibitors might increase ACE2 levels but the clinical significance of this is not clear. Continue ACE-i and ARBs say American and European societies

Steroids should only be used in a clinical trial setting say WHO

“WHO does not recommend against the use of ibuprofen” – their words not mine. We don’t know, but maybe avoid if you can. The NHS is advising paracetamol if safe.

Novel therapies

Didn’t your neighbour tell you that Trump said that there was a cure? It’s experimental, and there are risks, including sudden death.

Lopinavir-ritonavir doesn’t provide benefit beyond standard care in hospitalised adult patients

WHO to study novel therapies: lopinavir-ritonavir (with and without interferon beta), chloroquine and hydroxychloroquine, and remdesivir

Care homes

This blog is mostly about hospital management, but I am a sometimes community geriatrician when I’m not in a pandemic so have a look at these excellent BGS guidelines. The disease can move through care homes rapidly with high hospitalisation and mortality rates. If you’re looking after a care home, take heed of the messages in this paper, the BGS guidance and the guidance from the CDC. If you work in a care home, or are discharging patients to a care home, you’ll want to know this national guidance.

Cognitive bias

We are about to enter a world where it will look like everyone has novel coronavirus. But other infections and other diagnoses aren’t going to completely disappear. Think about how you think, and consider some of the cognitive biases we are all prone to.

Look after yourself

We are also about to enter some very tough times. After the event, we need to consider how to prepare better for next time, and how to fight for a better resourced system. But for now, look after yourself and find ways to manage stress. There is a nice long list of resources, including local services on the Yorkshire Deanery website. Some great posters on the Intensive Care Medicine Society website. It’s ok to not be ok.

Love this advice from Suzette Woodward – something to add to safety huddles?

Some other things

Coronavirus will go but it will also be back, “like a sh*t Terminator.” If you haven’t done basic life support recently, try this instructional video from The Office USA. If you feel like you’ve got a to do list longer than a Leonard Cohen song and you need a good swear, this is very therapeutic.

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